Thompson: Managing pain by proper opioid prescribing is now in danger

National pain awareness week has just started. It is likely, however, that the ongoing opioid crisis will overshadow awareness of the chronic problem of pain. The war on drugs and the war on pain have become conflated in the ongoing opioid crisis.

The tragedy of hundreds, even thousands, of drug overdose deaths has understandably taken precedence in the news media. Governments have responded to the crisis, but some of the actions taken are highly unlikely to solve the problem of overdoses and needless deaths; meanwhile, they will make life very difficult for individuals with chronic pain and for the physicians looking after them.

Key facts need to be remembered. The “War on Drugs” was declared by then-U.S. president Richard Nixon in 1971, several decades before individuals with chronic pain starting receiving prescriptions for opioids. From about 2000 on, prescribed opioids became popular with drug addicts and drug abusers, who gained access to supplies of OxyContin using a variety of methods including pharmacy break-ins. Many physicians prescribing opioids were deceived by such people, and a few were careless in their prescribing.

By spring 2012, the formulation of OxyContin had been changed into tablets that were not as easily abused, in that they could not be crushed and snorted or injected. The street value of these tablets plummeted and the number of break-ins into pharmacies dropped.

This situation represented a business opportunity for criminal organizations importing bootleg/illicit drugs from China and elsewhere. Illicit tablets made to look like the old OxyContin flooded the streets. They contain fentanyl in various quantities and even some carfentanil, a very deadly synthetic opioid also known a “the elephant drug” (it was initially designed to tranquilize large animals). A Citizen article in May 2017 described this in detail. But Ontario officials seemed unaware of it.

At the national “opioid summit” held in Ottawa a year ago, ministers of health from British Columbia and Alberta described the impact of bootleg fentanyl in their jurisdictions. Dr. David Williams, Ontario Chief Medical Officer of Health, gave a talk later that day stating that in Ontario prescribed opioids were the real problem. This information was inaccurate, and unfortunately resulted in an unprecedented crackdown by the Ontario College of Physicians and Surgeons on 84 Ontario pain physicians found to have been prescribing higher doses of opioids than the much-reduced limit now adopted by the College.

Some of these 84 were world leaders and highly respected physicians. Certainly a review of practices, and remediation where indicated, would have been constructive. Instead, the draconian measures taken have been enormously costly both for individual physicians and for the profession as a whole. They will do nothing to stop the overdose deaths and will not curb the opioid epidemic. And these actions have already had a very negative impact on chronic pain patients.

For example, a 57-year-old male who had been able to return to a demanding physical job by using a regular daily dose of oxycodone long-term, with no dose escalation and no aberrant behaviours, was told he would have to go down to half the effective dose, to comply with the college’s new directive. This may not work for him.

There have been reports of desperate patients trapped under the new, tougher prescribing policies, and even reports of a few suicides. So far, there are no confirmed requests for Medical Assistance in Dying by those who can no longer escape the pain, as they once could have.

Meanwhile, the facts remain: One in five Canadians suffers from chronic pain – 20 per cent of the population. Half of these, that is 10 per cent of all, have pain of such severity that they cannot work, play or sleep much. The cost to society of chronic pain equals that of cancer, heart disease and AIDS/HIV combined.

We had made good inroads with these problems, and proper opioid prescribing has been part of the solution. These gains are now in jeopardy.

Dr.Ellen N. Thompson is an anesthesiologist and chronic pain physician – as well as patient advocate – who hopes to retire, soon.

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